The aim of this study was to determine the torsional and 4-point bending properties of a midshaft humeral osteotomy reconstructed with either an intramedullary nail or locking plate.
A transverse midshaft osteotomy was created and a spacer ensured a constant 3-mm gap between the bone ends. Reconstruction was performed with either
Trigen humeral nail (Smith &
Nephew, TN) – 10 specimens Humeral locking plate (Synthes, PA) – 9 specimens Non-destructive 4-point bending was repeated, and then each humerus was embedded in a low-melting point alloy proximally and distally for torsional testing. Torque was applied at 5 deg/min until failure. Maximum torque, maximum angle and stiffness were calculated. All data were analysed with SPSS for Windows (SPSS Inc., Il) using ANOVA.
4-point bending: the bones reconstructed with the intramedullary nail were ~50% as stiff as the intact state in both planes. There was no statistically significant difference in stiffness between the intact bones and those reconstructed with the locking plate. Torsional testing: the locking plate specimens were 3 times as stiff as the intramedullary nail specimens (P<
0.05) and failed at twice the torque (P<
0.05).
Seven specimens were used for mechanical analysis. A humeral osteotomy was performed distal to the insertion of pectoralis major, leaving intact the biceps sheath and the muscle belly of long head of biceps. The proximal humerus was attached to a custom-designed jig and the muscle belly of biceps grasped in cryogenic grips. Specimens were loaded on an MTS 858 Bionix mechanical testing machine (MTS Systems, MN) in uniaxial tension at a rate of 1 mm/sec until failure was observed.
Histological examination of the biceps sheath revealed membranous tissue consisting of loose soft tissue with fat and blood vessels. Synovial tissue was also identified. The sheath was seen to loosely attach to the biceps tendon, with a more intimate attachment to the periosteum. The mean force to pull the long head of biceps tendon out of the sheath 102.7 N (range 17.4 N–227.6 N)
. There is less information on normal foetal hip . Magnetic resonance imaging (MRI) allows development to be followed in the healthy baby.
To establish normal patterns of hip development. To obtain charts that could be used to detect abnormality earlier. There are three aspects to this study:
Validation – analysing MRI scans of babies hips prior to post mortem (the gold standard) would verify MRI as a valid tool for such studies. Measurements will be gained for foetus in utero Similarly for pre and term babies.
For the initial validation process, parents who had consented to post mortem were asked to consider additionally an MR scan of their neonate’s hips, a total of 30 cases.
Measurements were made, by two independent observers, of the width and depth of the acetabulum and the radius &
diameter of the femoral head, volume and area were calculated. Inter-observer variation was assessed.
With the exception of the acetabular width each dimension showed little development until week 20 when the line of growth rose exponentially. The acetabular width showed only a slow rate of growth despite the changes seen in the femoral head. Levels of observer agreement were high (ICCs = 0.98) for all but depth (ICCs = 0.86). The measurements for all dimensions were in line with previous post mortem studies.
A retrospective review of our prospectively collected database was undertaken and the functional and oncologic outcomes after Type One pelvic resections for bone tumours of the ilium and sacrum were analyzed. Seventeen patients were identified with a minimum followup after resection of twelve months. In seven patients the bone defect was reconstructed, with no reconstruction in the remaining ten patients. The functional/oncologic outcomes of the two groups are similar, however patients without reconstruction had fewer complications and less dependence on walking aids suggesting that reconstruction may not be justified. Management of defects created by Type One pelvic resections of large iliac bone tumours remains controversial. We reviewed the functional/oncologic outcome following resection with and without reconstruction. Similar functional/oncologic outcome was achieved in both groups suggesting that reconstruction is not justified. A retrospective review of our prospectively collected database was undertaken analyzing functional/oncological outcome of seventeen patients with Type One pelvic resection. Minimum follow up was twelve months (12–96). Outcome data was available on 8/10 patients managed without reconstruction (WOR), with residual ilium collapsing back onto sacrum, and on 5/7 patients with bone graft reconstruction (WR). Average age thirty-three years (WOR) and 48yrs (WR), (p=0.04), with average maximal tumour dimensions of 12cm and 9cm (p=0.1). The most frequent diagnosis was chondrosarcoma. The WOR group average TESS, MSTS 87 and MSTS 93 scores were respectively 73%, 18/35 and 58% at an average of 50 months (24–96) compared to 69%, 21/35 and 51% at an average of 37 months (12–60) for the WR group. 33% of WOR and 20% of WR patients did not require walking aids. Infection or wound necrosis occurred in 40% of WOR patients and 57% of WR patients. No local recurrences. The perceived advantages of no reconstruction are shorter operating times, reduced incidence of complications and improved functional outcome due to medialization of the weightbearing axis in the absence of hip abductors. The oncologic/functional outcomes of both groups were similar but in those not reconstructed there was a lower incidence of complications and walking aids.
Many authors believe that size, histological grade and depth are the best predictors of outcome in soft tissue sarcoma. Enneking’s surgical staging system included compartmental status, and was intended to guide surgical intervention as well as provide prognostic information. Advances in surgical and radiotherapy techniques may mean that extracompartmental status is no longer a poor prognostic factor. We compared a group of popliteal fossa sarcomas with a group from the posterior thigh, and found that although the former group required more extensive surgery to obtain wide margins, their functional and survival outcomes were similar. No single staging system has been generally accepted for extremity soft tissue sarcoma, although histologic grade, size and depth are widely accepted as prognostic indicators. Enneking outlined a surgical staging system which used compartmental status as a predictor of outcome. However, surgical reconstruction and adjuvant radiotherapy have advanced considerably. We wanted to know if a tumour arising in the popliteal fossa still had poorer survival or functional outcome in the light of these advances. We identified twenty-three patients who had sarcomas of the popliteal fossa and forty-six patients who had sarcomas of the nearby posterior thigh compartment. Popliteal sarcomas were not of a different size or more likely to present with metastasis. Popliteal tumours more frequently required reconstructive techniques such as local or free tissue transfer and skin grafting than posterior thigh tumours (39.1% v 4.3% respectively). Popliteal tumours were also more likely to undergo a dissection or reconstruction of the major neurovascular structures of the lower limb (30.4% v 0% respectively). There was no difference in local or systemic recurrence rates between the groups. TESS and MSTS 1987 functional scores also showed no difference between the groups. We conclude that popliteal fossa sarcomas require a greater level of surgical intervention to follow sound principles of sarcoma resection and achieve reconstruction of the ensuing soft tissue defect. However, if these principles are followed in a planned multidisciplinary setting, then survival and functional results similar to the posterior thigh can be expected.
A retrospective review of our prospectively collected database was undertaken to determine the functional and oncologic outcome following combined pelvic allograft and total hip arthroplasty (THA) reconstruction of large pelvic bone defects following tumour resection. There were twenty-four patients with a minimum followup of fifteen months. The complication rate following hemipel-vic allograft and THA reconstruction of resection Types I+II and I+II+III was high, but when successful this reconstruction resulted in reasonable functional outcome. In comparison, the functional outcome after allograft and THA reconstruction of isolated Type II acetabular resections was better and more predictable. Resection of large pelvic bone tumours often results in segmental defects with pelvic discontinuity and loss of the acetabulum. We reviewed the functional and oncologic outcomes following pelvic allograft and total hip arthroplasty (THA) reconstruction. Reconstruction of large pelvic defects including the acetabulum using hemipelvic allograft and THA is associated with high complication rates, however when successful provides reasonable function. In comparison, the outcomes of allograft and THA for acetabular defects alone are better and more predictable. A retrospective review of our prospectively collected database was undertaken. Minimum followup was fifteen months (15–167). Nineteen patients were hemipel-vic resections (twelve Type I+II and seven Type I+II+III, eleven cases including partial sacral resection) reconstructed by hemipelvic allograft and THA. Five patients had Type II acetabular resections, reconstructed with structural allograft, roof ring and THA. Osteosarcoma and chondrosarcoma were the most frequent tumours. All patients required walking aids. In the hemipelvic group there were two early deaths (peri-operative haemorrhage and aplastic anaemia). In seven patients (37%) the allograft remained intact without infection but three required revision THA for loosening. For these seven patients the functional outcome scores were TESS 64%, MSTS87 17/35 and MSTS93 of 45% (mean fifty-two months.). There were nine cases of deep infection (47%) with three patients maintaining a functional implant. The nineteenth patient was revised following allograft fracture. In the Type II acetabular group, three patients had no complications, and two patients dislocated. The average scores were TESS 78%, MSTS87 21/35 and MSTS93 64% (mean fifty-five months).
The outcome of complex acetabular reconstruction was evaluated in twenty-one patients who were confined to a wheelchair or bed because of pain from acetabular metastases. Reconstruction rings were used where bone loss exceeded 50% of the acetabulum. Six roof reinforcement-rings, eight ilioischial-rings and eight Harrington reconstructions were performed. All but two patients(90%) became ambulatory without pain. Median survival was nine months. Two patients underwent acetabular revision for recurrence. These results support the role of acetabular reconstruction for palliation of pain in appropriate patients with acetabular metastases. Metastatic disease of the acetabulum is painful and disabling. Operative intervention is indicated in certain patients with pathologic fractures, and non-responders to adjuvant treatment. The functional outcome of hip arthroplasty with reconstruction rings was evaluated in twenty-one patients with acetabular metastases between 1989 and 2001. Preoperatively all patients were confined to a wheelchair or bed and used significant narcotic medications. Preoperative radiotherapy was employed in eighteen cases (90%) and 30% had undergone chemotherapy. AAOS classification of the acetabular lesion revealed: six-type II, seven-type III and eight-type IV deficiencies. All cases required a reconstruction ring due to bone loss exceeding 50% of the acetabular dome. Six roof reinforcement rings, eight ilioischial rings and eight Harrington reconstructions with rings were performed in this group. Determination of the reconstructive technique was based on preoperative computerized tomography and intraoperative examination of the acetabular deficiency. All but two patients (90%) became ambulatory without significant pain. Eleven patients used a walker or two canes and nine walked with one or no canes. Median survival was nine months and patients with visceral involvement had a shorter duration. Eight early post-operative complications developed in six patients (29%). In two patients the acetabular construct failed with cup migration due to locally recurrent disease; both were successfully revised. The results of complex acetabular reconstruction for metastatic disease validate its role for palliation of pain and to improve ambulatory status. Preoperative planning with computerized tomography can assist in classifying acetabular bone loss and determining optimal reconstruction technique.
Considerable differences in kinematics between different designs of knee prostheses and compared to the natural knee have been seen in vivo. Most noticeably, lift off of the femoral condyles from the tibial insert has been observed in many patients. The aim of this study was to simulate lateral femoral condylar lift off in vitro and to compare the wear of fixed bearing knee prostheses with and without lift off. Twelve PFC Sigma cruciate retaining fixed bearing knees (DePuy, Leeds, UK) were tested using six station simulators (Prosim, Manchester, UK). The kinematic input conditions were femoral axis loading (maximum 2.6 kN), flexion-extension (0–58°), internal/external rotation (±5°) and anterior/posterior displacement (0–5 mm). Six knees were tested under these standard conditions for 4 million cycles. Six knees were tested under these conditions with the addition of lateral femoral condylar lift off, for 5 million cycles. The lubricant used was 25% newborn calf serum. Wear of the inserts was determined gravimetrically. Under the standard kinematic conditions the mean wear rate with 95% confidence limits was 8.8 ± 4.8 mm 3/million cycles. When femoral condylar lift off was simulated the mean wear rate increased to 16.4 ± 2.9mm 3/million cycles, which was statistically significantly higher (p <
0.01, Students t-test). The wear patterns on the femoral articulating surface of all the inserts showed more burnishing wear on the medial condyle than the lateral. However, in the simulation of lift off the medial condyle was more aggressively worn with evidence of adhesion and surface defects. The presence of lateral femoral condylar lift off accelerated the wear of PFC Sigma cruciate retaining fixed bearing knees. The lateral lift off produced uneven loading of the bearing, resulting in elevated contact stresses and hence more wear damage to the medial side of the insert. The implications of condylar lift off include increased wear of the polyethylene and possible osteolysis.
Forty-six patients with an uncemented proximal tibial endoprosthesis were reviewed following resection of a proximal tibial tumor. The mean age was thirty-four years and the majority were male. The most common malignant diagnosis was osteosarcoma. Oncologic and functional analysis was performed on these cases. At latest follow-up thirty of the patients remain alive with no evidence of disease and eleven had died. The most common complication was deep infection (7/46). Only six patients had mechanical prosthesis related complications. At latest follow up the average TESS score was 76.3 and MSTS score 75.5 with an average extensor lag of 6.5o. To review the oncologic and functional results of a series of forty-six uncemented proximal tibia tumour replacements. A retrospective review of our prospectively collected database revealed forty-six patients with an uncemented proximal tibial replacement following tumour excision. The data was analysed with respect to patient demographics, operative and prosthetic complications. Oncologic diagnosis and results and functional results were also reviewed. The average age of the forty-six patients was thirty-four years (14–73) with thirty-three males and thirteen females. The most common diagnosis was osteosarcoma. There were four cases of benign GCT. At an average follow-up of 85.8 months (11–170), thirty were alive with no evidence of disease while eleven patients had died of their disease. Four patients were alive with evidence of disease at latest follow-up and one patient had died of unrelated causes. The most common operative complication was infection (9/46) with seven of these being deep infections requiring prosthesis removal, followed by mechanical problems including stem fracture (3/46) and bushing failure (3/46) also requiring operative intervention. Functional assessment revealed an average extensor lag of 6.5o with an average ROM of 83.6o, average TESS scores of 76.3 and MSTS 93 scores of 75.5. Large series of uncemented proximal tibial endoprostheses are uncommon in the literature. In our series there is a low rate of aseptic loosening at an average seven year follow-up, but this is offset by problems including infection and prosthetic fracture. Overall the functional and oncologic results remain satisfactory.
As patients live longer following treatment for soft tissue sarcomas, complications from treatment will continue to emerge. Predicting which patients are at risk allows for improved preoperative planning, treatment, and surveillance. The data presented here suggests that females greater than fifty-five years of age treated with high dose, postoperative radiotherapy in combination with limb salvage surgery for soft tissue sarcomas are at an increased risk of post irradiation fractures. Unlike previous reports, a significantly higher rate of fracture occurred in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy). This retrospective study was performed to determine if the timing and dosage of radiotherapy are related to the risk of post radiation pathologic fracture following combined therapy for lower extremity soft tissue sarcomas. Three hundred sixty-four patients with sarcomas treated with external beam radiation therapy and limb salvage surgery were evaluated. High dose radiation was defined as 60 Gy or 66 Gy; low dose as 50Gy. Radiation timing schedules were preoperative, postoperative, or preoperative with a postoperative boost. Univariate and multivariate analysis was used to determine which factors were associated with fracture risk. Twenty- seven pathologic fractures occurred in twenty-three patients. Twenty- four fractures occurred in twenty patients who were treated with high dose radiation. Sixteen of these patients had postoperative radiation (fourteen patients received 66Gy, two received 60Gy), and four had pre-operative radiation with a postoperative boost (total dose = 66Gy). Three fractures occurred in three patients who received low dose preoperative radiation (50Gy). Both high dose radiation (versus low dose) (p=.001) and preoperative radiation (versus postoperative) (p =0.002) were associated with a risk of fracture. Findings in this study were consistent with previous reports in that females over fifty-five years of age who undergo removal of a thigh sarcoma combined with radiation therapy are at a higher risk of a pathologic fracture, and differs in that there was a significantly higher rate of fracture in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy), and when radiation therapy was given postoperatively versus preoperatively.
Two hundred and forty-one patients with extremity osteosarcoma presented to our institution between 1989 and August 2002, thirty-six of whom had a pathologic fracture. There were twenty-five limb salvage surgeries and ten primary amputations, with three limb salvage surgeries requiring secondary amputations. One patient had an unresectable tumor and was treated palliatively. At mean follow-up of 96.9 months there was one local recurrence and eighteen patients were alive without disease in the pathologic fracture group. There was no survival difference between the pathologic fracture group with no metastases at presentation and the non-pathologic fracture group with no metastases (119.4 months vs 134.3 months, log rank 0.83, p=0.36). To examine the outcome of osteosarcoma patients that present with a pathologic fracture as compared to those patients without a pathologic fracture. There was no significant difference in the rate of amputation vs limb salvage surgery in osteosarcoma patients that presented with a pathologic fracture as compared to those without. There was no difference in the two groups’ disease-free and overall survival, for those patients that presented without metastatic disease. Presentation with a pathologic fracture in osteosarcoma does not preclude limb salvage surgery and is not a prognostic indicator for decreased survival. Retrospective review of all patients presenting to our institution with extremity osteosarcoma between 1989 and August 2002. There were two hundred and forty-one patients with extremity osteosarcoma, thirty-six of whom presented with a pathologic fracture. In the pathologic fracture group, there were nineteen males and seventeen females. Twenty-five were treated with limb salvage surgery, ten required a primary amputation and one was unre-sectable. Three limb salvage surgery patients required a secondary amputation. Sevenpatients presented with metastatic disease. Twenty-eight of the thirty-six patients received (neo) adjuvant chemotherapy. At last follow-up, eighteen patients were alive no evidence of disease (51.4%), three were alive with disease, eleven were dead of disease and three were deceased from other causes. There was one local recurrence (2.8%). Mean overall survival was 119.4 months (0–147.1) for patients with a pathologic fracture and no metastasis at presentation and 134.3 months (0–172.5) for patients with no pathologic fracture and no metastasis (log rank 0.83, p=0.36).
This study was undertaken to assess the contribution of pulmonary fat embolism caused by intramedullary femoral canal pressurization to the development of acute lung injury in the presence of resuscitated hemorrhagic shock. Twenty-seven NZW rabbits were randomly assigned into one of four groups: resuscitated hemorrhagic shock and fat embolism, resuscitated hemorrhagic shock, fat embolism, and control. Fat embolism was induced via intramedullary cavity with a 1–1.5 ml bone cement injection. Only the animals that underwent resuscitated shock and fat embolism displayed amplified neutrophil activation and alveolar infiltration. These findings suggest that the combination of resuscitated shock with fat embolism initiates an inflammatory response, which may play a role in the development of fat embolism syndrome. The objective of this study was to assess the contribution of pulmonary fat embolism caused by intramedullary femoral canal pressurization to the development of acute lung injury in the presence of resuscitated hemorrhagic shock. Only the animals that underwent resuscitated shock and fat embolism displayed amplified neutrophil activation and alveolar infiltration. These findings suggest that the combination of resuscitated shock with fat embolism initiates an inflammatory response, which may play a role in the development of fat embolism syndrome. CD11b mean channel florescence was only significantly elevated in the HR/FE group at two and four hours post knee manipulation. Moreover, greater infiltration of alveoli by leukocytes was only significantly higher in the HR/FE group as compared to controls. Twenty-seven NZW rabbits were randomly assigned into one of four groups: resuscitated hemorrhagic shock + fat embolism (HR/FE), resuscitated hemorrhagic shock (HR), fat embolism (FE), and control. Hypovolemic shock was induced via carotid bleeding for one-hour prior to resuscitation. For fat embolism induction, the intramedullary cavity was drilled, reamed and pressurized with a 1–1.5 ml bone cement injection. For evaluation of neutrophil activation, blood was stained with antibodies against CD45 and CD11b and analyzed with a flow cytometer. Animals were mechanically ventilated for four hours post surgical closure. Postmortem thoracotomy was performed, and three stratified random blocks of each lung were processed for histological examination. Our findings suggest that FE by itself does not cause lung injury, as there were no apparent differences between the control and FE animals. Only the HR/FE animals revealed a higher number of infiltrating neutrophils into alveolar spaces and greater neutrophil activation.
To review the results of limb lengthening and deformity correction in fibular hemimelia, fifty-five patients with fibular hemimelia underwent limb reconstruction at Sheffield Children’s Hospital. According to Achter-man and Kalamchi classification, twenty-six were classified as Type IA, six as Type IB and twenty-three as Type II fibular hemimelia. All patients had at least some shortening of ipsilateral femur but forty-nine had sig-nificant femoral deficiency. Lengthening of tibia and in significant cases femur was done using De Bastiani or Vilarrubias or Ilizarov methods. Ankle valgus and heel valgus were corrected through osteotomies either in the supramalleolar region or heel. Equinus was corrected by lengthening of tendoachelis with posterior soft tissue release and in severe cases using Ilizarov technique. The average length gained was 4.2 cm (range 1 to 8) and the mean percentage of length increase was 15.82 (range 4.2 to 32.4). Mean bone healing index was 54.23 days/cm. Significant complications included knee subluxation, transient common paroneal nerve palsy, and recurrence of equinus and valgus deformity of foot. Overall alignment and ambulation improved in all patients. Knee stiffness due to cruciate deficient subluxations needed prolonged rehabilitation. Presence of 3-ray foot gives a better functional result and cosmetic acceptance by patients. The Ilizarov frame has the advantage to cross joints and lengthen at the metaphysis. Limb reconstruction in fibular hemimelia using limb lengthening and deformity correction techniques improve functional status of involved lower limb.
In this paper, a retrospective review was undertaken of a large musculoskeletal tumour database to identify patients who presented with tumours of the foot and ankle. Soft tissue tumours occurred more frequently than bone tumours, and were also more frequently malignant than bone tumours. In contrast to the more recent trend towards limb-preserving surgery in other anatomic areas, malignant tumours of the foot and ankle were frequently unresectable and were treated with amputation. Although the majority of extremity tumours that present to the orthopaedic surgeon are found in the proximal limbs or around the knee, tumours of the ankle and foot are also relatively common. The purpose of this study is to identify the frequency with which benign and malignant bone and soft tissue tumours occur in the foot and ankle and the oncologic and surgical outcomes of these patients. A retrospective review of a large musculoskeletal tumor database in a tertiary referral center from the years 1986–2002 was undertaken. For oncologic outcomes, a minimum two-year follow up was considered. A total of one hundred and sixteen bone and one hundred and seventy-one soft tissue tumours were identified. Seventy-seven bone tumours were benign and thirty-nine were malignant. Sixty-six soft tissue tumours were benign and one hundred and five were malignant. The most common benign bone tumour was giant cell tumour and osteosarcoma was the most common malignancy. Malignant fibrous histiocytoma was common in the distal leg but synovial sarcoma and clear cell sarcoma were more common in the foot. Twenty patients with bone malignancies (51%) and twenty-four with soft tissue sarcomas (23%) had amputation as definitive surgical management. Death from metastases occurred in 25% of patients with bone malignancies and 10% of soft tissue sarcomas. At this center, the majority of bone tumours treated are benign but the majority of soft tissue tumours are malignant. Limb salvage is often not possible and amputation for local tumour control is necessary far more often than in other anatomic sites.
Lymph node metastasis in soft tissue sarcoma is considered to be a rare event (1.6–8.2%), From 1986 to 2001 1066 patients with extremity soft tissue sarcoma were treated surgically (+/− adjuvant therapy) at our institution. Thirty-nine patients (3.6%) were identified with lymph node metastasis, most common histological subtypes were: Epitheliod sarcoma (3/15), rhabdomyosarcoma (4/21), clear cell sarcoma (2/18), and angiosarcoma (2/18). Comparing expected five- year survivorship, we found that surprisingly in this study, extremity soft tissue sarcoma patients initially presenting with lymph node metastases had survival comparable to patients with high grade soft tissue sarcoma and no metastases. To determine the outcome in patients with soft tissue sarcoma (STS) of the limbs that presented with lymph node metastasis (LNM) at diagnosis or developed them after it, comparing to all STS of limbs population that was treated at our center. LNM in soft tissue sarcoma is considered to be a rare event (1.6–8.2%) with a devastating effect on the outcome,our study represent one of the largest reported cohorts, and suggest that agressive approach to LNM might contribute to survivorship. Thirty-nine patients (3.6%) were identified with LNM along their course of disease Thirteen patients presented with both lymphatic and systemic disease while twenty-six had isolated LNM at time of diagnosis. The mean follow-up from diagnosis of the primary tumor was 46.3 months (range zero to one hundred and forty-eight), and from diagnosis of lymph node involvement was 29.9 months (range zero to one hundred and twenty). Expected five year survival in patients initially presenting with LNM was comparable to patients with high grade soft tissue sarcoma and no metastases. From Jan’ 1986 to Dec’ 2001 1066 patients with extremity STS were treated at our institution. Fifteen patients presented with LNM at time of first diagnosis, and twenty-four subsequently developed LNM after it. Linear regression analysis and Kaplan-meier curves were used to compare expected survivorship in all patients with STS of limbs. Comparing expected five- year survivorship, we found that Surprisingly in this study, extremity STS patients initially presenting with LNM had survival comparable to patients with high grade soft tissue sarcoma and no metastases.
To review the results of reconstruction of pseudoar-throsis and/or significant varus with retroversion of proximal femur in congenital longitudinal lower limb deficiencies, twenty-three of ninety-five patients with lower limb deficiencies underwent proximal femoral reconstruction at the Sheffield Children’s Hospital. All twenty-three underwent valgus derotation osteotomies to correct coxa vara and retroversion of femur. Seven patients also had pseudoarthrosis of the neck of femur. Three of these were treated with valgus derotation osteotomy and cancellous bone grafting, two with fibular strut grafts, one King’s procedure and one with excision of fibrous tissue and valgus derotation osteotomy. A variety of internal fixation devices and external fixator were used. Seventeen of the twenty-three patients had valgus osteotomies repeated more than once (average 2.3) for recurrence of varus deformity. Average initial neck-shaft angle was 72 degrees, which improved to an average of 115 degrees after reconstruction. All seven patients with pseudoarthroses underwent multiple procedures (average 3.3) to achieve union. Cancellous bone grafting was repeated twice in two patients to achieve union but all three with cancellous bone grafting underwent repeat osteotomies to correct residual varus. Two patients achieved union after fibu-lar strut grafting. One patient, who underwent excision of pseudoarthrosis, achieved union but had to undergo further valgus osteotomy. No particular advantage of any one-fixation device over the others was noted in achieving correction. Early axis correction using valgus derotation oste-otomy is important in limb reconstruction when there is significant coxa vara and retroversion, although recurrence may require repeated osteotomies. Pseudoarthro-ses needed more aggressive surgery to achieve union.
Twenty-three patients with scapular chondrosarcomas presented to our institution between 1989 and 2003. Twenty-two were treated surgically while one presented with metastases and was treated palliatively. Fourteen patients underwent partial scapulectomy and eight had a Tikhoff-Linberg procedure. There were no local recurrences and only two patients have suffered a systemic recurrence at mean follow-up of fifty-two months. Mean functional scores were: TESS – 88, MSTS 1987 – 27 and MSTS 1993 – 84. Overall, the oncologic and functional outcome for these patients was excellent. To examine the oncologic and functional outcome of patients treated for chondrosarcoma of the scapula. Rates of local recurrence and metastasis for adequately treated chondrosarcomas of the scapula were very low and patient function was quite good. Unlike previous reports in the literature, we found that scapular chondrosarcomas are highly amenable to limb salvage surgery and the oncologic and functional outcomes are excellent. Retrospective review of our prospectively collected database for all patients treated surgically at our institution for scapular chondrosarcoma between 1989 and 2003. Twenty-three patients presented with scapular chondrosarcoma, but one had spine metastases and was treated palliatively. Thus twenty-two patients were treated with limb salvage surgery. There were fourteen males and eight females. One patient presented as a local recurrence. Four tumors were grade one, sixteen grade two and two grade three. Eight were secondary to a primary benign primary tumor of bone. There were fourteen partial scapulectomies and eight Tikhoff-Linberg procedures. Surgical margins were positive in three cases. two patients received post-operative radiation and no patients received adjuvant chemotherapy. At last follow-up, twenty patients were alive with no evidence of disease (90.9%), one was alive with disease and one was dead of disease. There were two systemic recurrences and no local recurrences at an average follow-up of fifty-two months (range 12–113). Mean functional scores were: TESS – 88, MSTS – 1987 27 and MSTS 1993 – 84.
Interest in football continues to increase, with ever younger age groups participating at a competitive level. Football academies have sprung up under the umbrella of professional clubs in an attempt to nurture and develop such talent in a safe manner. However, increased participation predisposes the immature skeleton to injury. Over a five-year period we have prospectively collected data concerning all injuries presenting to the medical team at Newcastle United football academy. We identified 685 injuries in our cohort of 210 players with a mean age of 13.5 years (9 to 18). The majority of injuries (542;79%) were to the lower limb. A total of 20 surgical procedures were performed. Contact injuries accounted for 31% (210) of all injuries and non-contact for 69% (475).The peaks of injury occurred in early September and March. The 15- and 16-year-old age group appeared most at risk, independent of hours of participation. Strategies to minimise injury may be applicable in both the academy setting and the wider general community.
We changed our pin tract care practice from 1996. We had a significant decrease in pin tract infections since then (p<
0.0001). We also found that using Ilizarov wires had significantly less infections than with half pins used with monolateral fixators (p<
0.0001; linear trend, p= 0.0338). There were 48 patients that required hospital admissions for IV antibiotics. and of these 10 patients required debridement. There were no residual long lasting infections or chronic osteomyelitis.
Viscosupplementation is the current treatment modality for early stage arthritis and in some cases for delaying joint replacement procedures. Rheological properties similar to that of synovial fluid and high molecular weight have been recognized as the determining factors in hyaluronic acids (HA) therapeutic and analgesic value (
Recent studies have assessed operative skill in surgical trainees “objectively” based on patient outcomes by attempting to statistically separate many contributory variables. Compression hip screw fixation (CHS) for neck of femur fracture (#NOF) is a standard operation commonly performed by orthopaedic trainees of varying experience. Our aim was to determine if trainees could be assessed objectively on their efficiency and aptitude in performance of this operation. A secondary aim was to evaluate the predictors of fixation failure for CHS described in the literature. Records and radiographs for all CHS performed by trainees of all levels for acute adult #NOF were examined retrospectively for 2 calendar years. Preoperative patient and fracture variables were scored. Outcome measures included operative time, scores of accuracy of fracture reduction and fixation, blood loss and complications. Failure of fixation was compared to the scores given to radiographs. Multivariate analysis was used to apportion variance between multiple contributing factors. Three hundred and eight two eligible operations were performed by 26 trainees. Operative time was effected by fracture complexity, trainee level and trainee operator (all p<
0.05). “Tip apex distance”, a measure of depth and centrality of screw placement in the femoral head, known to predict screw cut out was associated with trainee operator. Other outcome scores of fixation on radiographs were not correlated with fracture, patient or operator variables. Blood loss and complications were not associated with operator. The rate of failure of fixation was low and associated with scores of reduction quality only (p<
0.05). Trainees of variable experience perform CHS with a low overall complication rate and the most noticeable performance difference seems to be in speed of surgery.
To establish normal patterns of hip development. To obtain charts that could be used to detect abnormality earlier. There are three aspects to this study:
Validation – analysing MRI scans of babies hips prior to post mortem (the gold standard) would verify MRI as a valid tool for such studies. Similarly for a) fetuses in utero b) pre and term babies.
For the initial validation process, parents who had consented to post mortem were asked to consider additionally an MR scan of their neonate’s hips, a total of 30 cases.
Measurements were made, by two independent observers, of the width and depth of the acetabulum and the radius &
diameter of the femoral head, volume and area were calculated. Inter-observer variation was assessed.
With the exception of the acetabular width each dimension showed little development until week 20 when the line of growth rose exponentially. The acetabular width showed only a slow rate of growth despite the changes seen in the femoral head. Levels of observer agreement were high (ICCs 95% = 0.98) for all but depth (ICCs 95% = 0.86). The measurements for all dimensions were in line with previous post mortem studies.
In the Type II acetabular group, three patients had no complications, and two patients sustained dislocations. The average scores were TESS 78%, MSTS87 21/35 and MSTS93 64% (mean follow-up 55 months).
Acetabulum: Dysplastic/Non-dysplastic Ball (Head of femur): Present/Absent Cervix (Neck of femur): Pseudoarthrosis and neck-shaft angle Diaphysis of femur: Length/deformity Knee: Cruciates Fibula and Tibia: Length/deformity Ankle: Normal/Ball and socket/valgus Heel: Tarsal coalition/deformity Ray: Number of rays in the foot
We present the long-term results of pectoralis major transfer to restore elbow flexion in seven patients (ten procedures). The early results in all the patients were encouraging but with longer follow-up a gradual and progressive flexion deformity was observed with a decrease in the arc of flexion in eight elbows, reaching ≥ 90° in all cases. The results of pectoralis major transfer deteriorate with time due to the development of a recalcitrant flexion deformity of the elbow. With bilateral involvement we now recommend that the procedure be undertaken on one side only to allow the hand to reach the mouth for feeding, while the opposite side remains in extension for perineal toilet.
Deep infection complicating arthroplasty surgery carries a heavy fnancial and emotional burden on any orthopaedic service. The cost of hospital acquired infection is estimated at £1 billion per year 1 by the National Audit Office. Healthcare associated infection is an area currently under great scrutiny. Each NHS trust will have an Inspector of Microbiology, who will ensure the co-ordination of information required to diagnose healthcare associated infection. The Alexandra Hospital, Redditch has developed a dedicated elective orthopaedic ward free from multi resistant staphylococcus aureus (MRSA). that delivers high quality and high volume major joint replacement surgery through rigorous infection control. Between October 2001 and December 2002, the Alexandra hospital had an infection rate of 0.21% for total knee replacements compared to the national rate of 2.1% p= 0.002 (CI 0.00005–0.01) The infection rate for total hip replacements was 1.31% compared to 3.8% nationwide. p = 0.01 (CI 0.004–0.03). The total number of joint replacements performed per year increased from 256 in 2000 to 629 in 2002. We have developed a safe, effective and efficient orthopaedic unit within the framework of an NHS trust for a relatively modest investment. We believe the practical changes that have been made within our department can be repeated in other units around the country with relative ease.
The satisfaction of patients at both sites was analysed using a number of factors- the care provided was 79% before the move and 82% afterwards, their understanding of a nurse led service was rated as 73% and 85% respectively. Evaluation of the quality of information demonstrated that their questions had been answered well 78% and 75% respectively and the confidence and trust in the person providing the care was 91% and 89%. Failure by the IT department in delivering effective links to hospital computer system resulted in the LBOS data not being completed in the period following the move with logistical difficulties in clinic organisation.
Nine children with knee and foot deformities were treated by Ilizarov external fixation from 1989 to 2000 at the Sheffield Children’s Hospital. Sixteen cases of arthrogryposis were identified. Progressive correction was combined with soft tissue release, soft tissue distraction or bony correction. Clinical outcomes were assessed and comparisons made between the different treatment modalities. Three fixed flexion deformities of the knee treated with progressive correction and soft tissue distraction were corrected initially, but recurred some time after the removal of fixators. Out of five clubfoot deformities treated with an Ilizarov frame with progressive soft tissue distraction alone, three recurred despite long-term splinting. Eight clubfoot deformities were treated with a bony procedure combined with gradual correction in the circular frame, and all corrections were maintained at follow-up. The mean treatment time in the fixator was 17 weeks (12 to 50), and the mean follow-up time was 36 months. Complications included four cases of pin-tract sepsis, one case of osteitis requiring a sequestrectomy, one of transient neuropraxia and one fracture following removal of the fixator. The treatment of joint deformities in arthrogryposis remains challenging and complications occur. Combining the Ilizarov device with a bony procedure seems to give better results, with fewer recurrence of deformities than pure progressive soft tissue correction.
From our retrospective study. The five-year estimated survival rates were 55% for the group with a pathologic fracture and 77% for the group without a fracture (p = 0.02). Eleven (37%) of the 30 patients with a fracture who were managed with limb salvage and 10 (45%) of the 22 patients with a fracture who were managed with an amputation died of the disease (p = 0.50). The performance of a limb-salvage procedure in patients with pathologic fracture did not seem to significantly increase the risk of local recurrence or death.
The treatment of acetabular dysplasia in adolescents (age>
12) is difþcult and various complex pelvic osteotomies have been described. The aim of surgery being improvement in pain and to delay the onset of secondary osteoarthrosis.
We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods. The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions. We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI.
Complications other than AVN were re-subluxation (3), redislocation(4), fractures (1), ankylosis, LLD(4), infection (2). There was only 1 (5.9%) complication in primary referral group and 13 (30.2%) in tertiary referral group (p=0.050). Tonnis grade of subluxation, presence of ossific nucleus, tear drop shape, Mose’s grading, CE angle of Wiberg were documented but were not found to significantly affect the outcome.
Upper limbs are commonly involved in Arthrogyposis Multiplex Congenita. They may be involved in isolation or in combination with lower limbs. There are two patterns of involvement in upper limbs. The most common (type I) pattern presents with adduction and internal rotation at the shoulder, extension at the elbow, pro-nation of the forearm and flexion deformity of the wrist, indicating involvement of the C5 and C6 segments. These deformities can be quite disabling and may require surgery to help improve function. We present our long-term results with pectoralis major transfer procedure (as modified by senior author MJB) to restore elbow flexion in seven patients (ten procedures). Results: Early results in all our patients were quite encouraging. Six patients retained useful power in transferred pectoralis major muscle and maintained the arc of flexion, which was attained following tricepsplasty. However, as children were followed up a gradually increasing flexion deformity and decreasing flexion arc were observed in eight elbows. The onset and progression of flexion deformity was gradual and progressive. The flexion deformity reached ninety degrees or more in all cases. Conclusions: Results of pectoralis major transfer to treat extension contracture of the elbow in arthrogryposis deteriorate with time due to development of recalcitrant flexion deformity of the elbow. Presently we recommend this procedure on one side only in cases of bilateral involvement because if one procedure is carried out it would be possible for this hand to get to the mouth for feeding and the other unoperated side would be able to look after the perineal hygiene
Children with osteogenesis imperfecta(OI) have multiple long bone fractures with subsequent deformities. The mainstay of treatment is correction with multiple osteotomies and intramedullary fixation. The Shefffield intramedullary telescoping rod system has been successful in the treament of long bone fractures and deformities (Wilkinson et al ,JBJS-B,1998) Bisphosphonates (Pamidronate -1- 1.5mg/kg/day)have been used as adjuvant therapy in the treatment of OI since the last five years. The perceived benefits include reduction in fracture frequency, improvement in bone density and a general feeling of well being. We present our experience of five cases of OI who developed infections around thier Sheffield telescoping rods while on Pamidronate therapy. There was only one case of sepsis over a ten year period(over eighty patients)in a previously reported series from our centre. The time interval between the start of Pamidronate therapy and the diagnosis of infection varied between 12–36 months ie. between 4–12 cycles of Pamidronate (parenteral administration over a three day period at three month intervals). All patients had their intramedullary rods in situ from anywhere between 2–7 years. The infections were low grade with a 2–3 month period of dull ache prior to actual presentation. Intrestigly though all patients had multiple rods in situ, only one of their femoral rods was affected and they did not have any other infective focus at the time of diagnosis. Three patients presented with thigh abcesses while the other two presented with ipsilateral knee pain and effusion. All had raised inflammatory markers, radiological signs of sepsis with Staph Aureus the commonest infecting organism. Those cases presenting with abcesses were treated by drainage and rod removal, however only antibiotics were sufficient in the rest. The relationship between Pamidronate therapy and these infections is not absolutely clear and has not been reported previously. The possible links are discussed and a high degree of suspicion is recommended for those cases of OI on bisphosphonate
Objective: To review the hip subluxations or dislocations occurring during femoral lengthening in patients with congenital longitudinal lower limb deficiencies. Methods: Sixty-three patients with congenital longitudinal lower limb deficiencies underwent femoral lengthening using either De Bastiani, Villarubias or Ilizarov technique. Acetabular index, medial joint space, CE angle of Wiberg, acetabular angle of Sharp and neck-shaft angle were measured on anteroposterior radiographs of hip before, during and after lengthening. The Acetabulum was considered dysplastic when the Sharp angle was more than 45 degrees. Hip was considered to be subluxed when the medial joint space increased during lengthening. Results: During femoral lengthening, eleven hips sub-luxed as measured by the increase in medial joint space and one hip dislocated. All these hips had a preoperative acetabular index more than 25 degrees, CE angle less than 20 degrees and Sharp angle more than 45 degrees. The average neck-shaft angle was 75 degrees. Following subluxation, lengthening was stopped and the hips were reduced in hip spica after adductor and sartorius tenotomies. In one patient femoral shortening and acetabulo-plasty had to be done to reduce the subluxation. No case of avascular necrosis was noted. Conclusion: Hip subluxation during femoral lengthening of congenital longitudinal lower limb deficiencies tends to occur when the acetabular index is more than 25 degrees, Sharp angle is more than 45 degrees, CE angle is less than 20 degrees and when there is associated femoral coxa vara. Careful preoperative assessment is required, and if need be hip reconstruction prior to lengthening. Close monitoring during lengthening is recommended.
This study demonstrates that the NP documentation follows the guidelines identified by the RCGP, conversely it was not possible to assess from the GP documentation if all the steps had been followed. The mean average LBOS in the NP patients was slightly higher than those in the GP group, was this because these patients were having guideline applied care as opposed to “usual care”? Evaluation of the patient recall of information shows the NP sent five patients for X-ray even though this did not occur and is not recommended in guidelines. Conversely twenty-three patients can remember being given the “Back Book” by the GP but this was only documented in three cases. We believe that patient recall demonstrates an ineffective way to measure outcome and funding allocation for back pain management and needs to more accurately reflect the evidence.
Increased incidence of complications has been reported when lengthening limbs with underlying bone disorders such as dysplasias and metabolic bone diseases. There is a paucity of literature on limb lengthening in Osteogenesis Imperfecta (OI), probably due to the concern that the bone containing abnormal collagen may not tolerate the external fixators for a long term and there may not be adequate regenerate formation from this abnormal bone. We performed limb lengthening and deformity correction of nine lower limb long bones in six children with OI. Four children were type I and two were type IV OI as per Sillence classification. The mean age was 14.7 years. All six children had lengthening for femoral shortening and three of them also had lengthening for tibial shortening on the same side. Angular deformities were corrected during lengthening. Five limb segments were treated using a monolateral external fixator and four limb segments were treated using an Ilizarov external fixator. In three children, previously inserted femoral intramedullary nails were left in situ during the course of femoral lengthening. The average lengthening achieved was 6.26 cm. Limb length discrepancies were corrected to within 1.5 cm of the length of the contralateral limb in five children. In one child with fixed pelvic obliquity and spinal scoliosis, functional leg length was achieved. The mean healing index was 33.25 days/cm of lengthening. Among the complications significant ones included, one deep infection, one fracture through the midshaft of the femur, and development of anterior angulation deformity after the removal of the fixator in one tibia. Abnormal bone of OI tolerated the external fixator throughout the period of lengthening without any incidence of migration of wires and screws through the soft bone when distraction forces were applied. The regenerate bone formed within the time that is normally expected in limb lengthening procedures performed for other conditions. We conclude that despite abnormal bone characteristics, limb reconstruction to correct limb length discrepancy and angular deformity can be done safely in children with OI.
113 consecutive patients with soft tissue sarcoma treated by excision and reconstructive flaps were studied to assess the risk of complications and to compare local tumour control with those in whom primary wound closure was possible. Minimum follow-up was 24 months and mean age was 55 years (16–95). The sarcoma was located in the lower extremity in 83 and upper extremity 30 patients. Significant wound complications developed in 37 patients (33%). The most common complications were wound infections or partial necrosis occurring in 16% (18/113) and 13% (15/113) respectively. Complete flap necrosis requiring flap removal occurred in 6 patients (5%). Three patients (2.3%) required amputation as a result of complications. Significant risk factors for development of wound complications include location of tumour in the lower limb compared to upper limb (relative risk 2.3, p=0.02) and use of pre-operative radiotherapy compared to no or post-operative radiotherapy (relative risk 2.05, p=0.02). There was no difference in rates of complications in patients with free or pedicled flaps, tumours <
or >
5cm, distal or proximal location of tumour. The rates of negative excision margins (80%) and wound complications in patients who required reconstructive flaps were not different from that for the other patients treated at our centre who did not require reconstructive flaps. The use of soft tissue reconstructive flaps did not reduce the risk of positive excision margins or the rates of wound complications. The risk of amputation secondary to flap complication or failure is low.
Acute lateral dislocation of the patella has been associated with disruption of the medial restraints of the patella. Following non-operative management there is a redislocation rate of up to 44%. This is an observational study testing whether sonography is a reliable method of assessing the medial retinaculum after acute dislocation of the patella. Ten patients following acute patellar dislocation had an ultrasound scan (USS) performed by an experienced musculoskeletal radiologist. Each patient subsequently had an examination under anaesthetic, arthroscopy, and repair of the ruptured structures. The ultrasound reports were compared to the surgical findings to determine the accuracy of this investigation. USS located deficiencies in the ligamentous attachments to the medial border of the patella and the presence of avulsed bony fragments, all of which were confirmed at operation. The sonographic diagnosis of haematoma or torn fibres in the vastus medialis obliquus corresponded with our operative findings. The most significant findings were the correlation of free fluid around the medial collateral ligament (MCL) with avulsion of the femoral attachment of the medial patellofemoral ligament (MPFL) and the presence of avulsed fragments of bone from the medial border of the patella. Sonography, in cadaveric studies consistently identifies the retinacula and like MRI offers a distinctive constellation of findings that can be used in diagnosis and therefore play a significant role in directing surgical management of these patients. We have found Sonography to be readily available and accurate. This report does not include surgical outcome since the follow up is short and incomplete. We do, however, feel that ultrasound shows the state of the soft tissue restraints of the patella following lateral dislocation.
812 consecutive patients with soft tissue sarcoma of the extremity were studied to compare the characteristics and outcome of patients who had primary amputations and limb preserving surgery. Patients with primary amputations were more likely to have metastases at presentation, high-grade tumours, larger tumours and were older. The most frequent indications for primary amputation were tumour excision which would result in inadequate function and large extracompartmental tumours with composite tissue involvement including major vessels, nerves and bone. The requirement for primary amputation was a poor prognostic factor independent of tumour grade, tumour size and patients’ age.
To determine if rates of local recurrence and metastasis differ in upper versus lower extremity sarcomas. Prospectively collected data relating to patients undergoing limb-sparing surgery for extremity soft tissue sarcoma between January 1986 and April 1997 were analysed. Local recurrence-free and metastasis-free rates were calculated using the method of Kaplan and Meier. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and the Cox proportional hazards model. Of 480 eligible patients, 48 (10. 0%) had a local recurrence and 131 (27. 3%) developed metastases. Median follow-up of survivors was 4. 8 years (0. 1 to 12. 9). There were 139 upper and 341 lower extremity tumours. Upper extremity tumours were more often treated by unplanned excision before referral (89 vs 160, p<
0. 001) and were smaller (6. 0cm vs 9. 3cm, p<
0. 000). Lower extremity tumours were more often deep to or involving the investing fascia (280 vs. 97, p<
0. 003). The distribution of histological types differed in each extremity. Fewer upper extremity tumours were treated with adjuvant radiotherapy (98 vs. 289, p<
0. 000). The 5-year local recurrence-free rate was 82% in the upper and 93% in the lower extremity (p<
0. 002). Local recurrence was predicted by surgical margin status (hazard ratio 3. 16, p<
0. 000) but not extremity (p=0. 127) or unplanned excision before referral (p=0. 868). The 5-year metastasis-free rate was 82% in the upper and 69% in the lower extremity (p<
0. 013). Metastasis was predicted by high histological grade (hazard ratio 17. 28, p<
0. 000), tumour size in cm (hazard ratio 1. 05, p<
0. 001) and deep location (hazard ratio 1. 93, p<
0. 028) but not by extremity (p=0. 211). Local recurrence is more frequent after treatment for upper compared with lower extremity sarcomas. Variation in the use of radiotherapy and differences in histological type may be contributory. Metastasis is more frequent after treatment for lower extremity sarcomas because tumours tend to be large and deep.
Localised Langerhans-cell histiocytosis of bone (eosinophilic granuloma) is a benign tumour-like condition with a variable clinical course. Different forms of treatment have been reported to give satisfactory results. However, previous series all contain patients with a wide age range. Our aim was to investigate the effect of skeletal maturity on the rate of recurrence of isolated eosinophilic granuloma of bone excluding those arising in the spine. We followed up 32 patients with an isolated eosinophilic granuloma for a mean of five years; 17 were skeletally immature. No recurrences were noted in the skeletally immature group even after biopsy alone. By contrast, four of 13 skeletally mature patients had a recurrence and required further surgery. This suggests that eosinophilic granuloma has a low rate of recurrence in skeletally immature patients.
The aim of this study was to compare implementation of RCGP guidelines in patients in Primary Care with acute low back pain between GP and Nurse Practitioner. This report presents preliminary results. The intention was to recruit 200 patients presenting to GP with new episode of back pain. 50% randomised to NP care, 50% to GP care. Outcome measured by documentation audit and patient feedback. Individuals complete a questionnaire which includes a Low Back Outcome Score (LBOS) at 14 weeks, 6,12 and 24 months. All patients in NP arm given back book and advised against bed rest.
Initial results suggest no significant difference in outcome between GP and Nurse Practitioner patients. Of interest is that 10% and 13% of patients failed to recall important features of management. This implies that audit of healthcare processes by patient questionnaire may be unsatisfactory.
We considered whether a positive margin occurring after resection of a soft-tissue sarcoma of a limb would affect the incidence of local recurrence. Patients with low-grade liposarcomas were expected to be a low-risk group as were those who had positive margins planned before surgery to preserve critical structures. Two groups, however, were expected to be at a higher risk, namely, patients who had undergone unplanned excision elsewhere with a positive margin on re-excision and those with unplanned positive margins occurring during primary resection. Of 566 patients in a prospective database, 87 with positive margins after limb-sparing surgery and adjuvant radiotherapy were grouped according to the clinical scenario by an observer blinded to the outcome. The rate of local recurrence differed significantly between the two low- (4.2% and 3.6%) and the two high-risk groups (31.6% and 37.5%). This classification therefore provides useful information about the incidence of local recurrence after positive-margin resection.
We describe ten patients with Turner’s syndrome (karyotype 45, XO) who had leg lengthening for short stature. A high incidence of postoperative complications was encountered and many patients required intramedullary fixation as a salvage procedure. We discuss the reasons for this and highlight the differences between our findings and those of a similar series recently reported. In view of the considerable difficulties encountered, we do not recommend leg lengthening in Turner’s syndrome.
We describe a patient who developed avascular necrosis of both humeral trochleae after combination chemotherapy for acute lymphoblastic leukaemia. This presented as progressive stiffness of both elbows with little pain. Radiography and MRI confirmed the presence of avascular necrosis at both sites. This region corresponds to a watershed between the medial and lateral vascular arcades which supply the distal humerus and may explain the susceptibility of this bony region to avascular necrosis. Treatment involved capsulectomy of the elbow and removal of osteophytes giving a good functional outcome on both sides.
We used dual-energy x-ray absorptiometry (DEXA) to evaluate the extent of periprosthetic bone remodelling around a prosthesis for distal femoral reconstruction, the Kotz modular femoral tibial replacement (KMFTR; Howmedica, Rutherford, New Jersey). A total of 23 patients was entered into the study which had four parts: 1) 17 patients were scanned three times on both the implant and contralateral legs to determine whether the precision of DEXA measurements was adequate to estimate bone loss surrounding the anchorage piece of the KMFTR; 2) in 23 patients the bone mineral density (BMD) in different regions of interest surrounding the diaphyseal anchorage was compared with that of the contralateral femur at the same location to test whether there was consistent evidence of loss of BMD adjacent to the prosthetic stem; 3) in 12 patients sequential studies were performed about one year apart to compare bone loss; and 4) bone loss was compared in ten patients with implants fixed by three screws and in 13 without screws. The mean coefficients of variation (SD/mean) for the 17 sets of repeated scans ranged from 2.9% to 7.8% at different regions of interest in the KMFTR leg and from 1.4% to 2.5% in the contralateral leg. BMD was decreased in the KMFTR leg relative to the contralateral limb and the percentage of BMD loss in general increased as the region of interest moved distally in the femur. Studies done after one year showed no consistent pattern of progressive bone loss between the two measurements. The ten patients with implants fixed by screws were found to have a mean loss of BMD of 42% in the most distal part of the femur, while the 13 without screw fixation had a mean loss of 11%. DEXA was shown to have adequate precision to evaluate loss of BMD around the KMFTR. This was evident relative to the contralateral leg in all patients and generally increased in the most distal part of the femur. In general, it stabilised between two measurements taken one year apart and was greater surrounding implants fixed by cross-locking screws.
The Sheffield Expanding Intramedullary Rod System was developed after experiencing problems with existing rod systems in the management of osteogenesis imperfecta. Between 1986 and 1996 we treated 74 bones in the lower limb in 28 children at a median follow-up of 5.25 years. We have reviewed 24 children with a total of 60 rods. Before surgery, all children had had multiple fractures of the lower limb. At review eight patients had experienced no further fractures, but three had suffered five or more subsequently. Before initial stabilisation, 15 children had never walked, and only three (13%) used walking as their main means of mobility. After surgery, half of those who showed motor arrest were able to walk (p = 0.016). The number of patients able to walk, with or without aids, increased to 17 (p = 0.0001). We have experienced no evidence of epiphyseal damage after the procedure, and complication rates requiring rod exchange have been low (7%).
We report three complete ruptures and one partial rupture of the flexor pollicis longus tendon in association with the insertion of a volar plate for the treatment of fracture of the distal radius. Rupture was associated with the chronic use of steroids.
We describe the functional results in 14 patients (7 men, 7 women) after subtotal scapulectomy for primary bone and soft-tissue tumours at a specialist musculoskeletal oncology unit. Eight had chondrosarcomas, two Ewing’s sarcomas, one aggressive fibromatosis and three soft-tissue sarcomas. The mean follow-up was 52 months (6 to 120). Analysis of residual symptoms and of range and strength of movement by physicians used the Musculoskeletal Tumour Society rating scale (MSTS). Physical disability was measured by the patients using the Toronto Extremity Salvage Score (TESS). All 14 patients are still alive, two with systemic disease. Nine had more than 80% of their scapula resected but the glenohumeral joint was preserved in all cases. Eight had full movement and another two achieved 90° of flexion. The mean functional results were good to excellent in all except three patients (mean MSTS = 71.6 and TESS = 79.9). Two of these three patients had considerable pain as a result of brachial neuropathy. Scapulectomy gives an excellent functional result if the glenohumeral joint is preserved. The rotator cuff could be removed without a severe functional deficit provided that the deltoid was reattached to the scapular remnant and the trapezius.
We studied the quantity and rate of formation of new bone during lengthening of 17 limb segments in 10 patients using dual-energy X-ray absorptiometry (DEXA), ultrasonography and radiography. Whereas new bone was detected by both DEXA and ultrasonography within 1 to 2 weeks of distraction, it was not visible on the radiographs until 4 to 8 weeks. Limb alignment and gap measurement were accurately assessed by DEXA without the need for standard radiographs or scanograms. With ultrasound the distraction gap appeared as an echolucent window which narrowed progressively producing a hyper-reflecting line after which further consolidation could not be assessed. As measured by DEXA the density of the new bone at this stage was approximately 45% of control values and did not represent normal cortication. Whereas ultrasound could be used to identify defects in mineralisation and to determine when to dynamise the fixator system, DEXA could measure the quantity and rate of formation of bone throughout lengthening.
We measured the extent and rate of new bone formation over an 18-month period before, during and after the lengthening of ten leg segments in six patients aged between 8 and 18 years, using dual-energy X-ray absorptiometry (DEXA). New bone formation could be identified within one week of the start of distraction. As lengthening proceeded, the bone density of the gap fell, reaching minimum values at the time of maximal distraction. Consolidation of the regenerating bone was started 1 to 2 weeks later in the tibia, and 2.5 to 3.0 weeks later in the femur. The rate of mineral accretion in new bone was significantly greater in the tibia than in the femur (16 +/- 1.86%/month, and 11 +/- 1.1%/month respectively; mean +/- SEM). There was significant osteoporosis distal to the osteotomy, more in the tibia than in the femur, particularly on the side of the fixator. The bone mineral density of the distal segment remained low at the time of fixator removal (44.2 +/- 5.58% and 61.0 +/- 4.2% of the control values at the tibia and femur respectively) and was only partially reversed by subsequent weight-bearing. We conclude that dual-energy X-ray absorptiometry provides an objective and quantitative assessment of new bone formation during leg lengthening. The technique also allows the measurement of the distraction gap and the assessment of leg alignment from the high-resolution images. Its use may decrease the requirements for conventional radiography.
We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.
We discuss the role of primary knee arthroplasty in supracondylar and intercondylar fractures of the femur in elderly patients with reference to 13 cases. This method of treatment is shown to be effective and to have good results. It is recommended for all type C and some type A supracondylar fractures in old people.
Five patients with Boyd type II congenital pseudarthrosis of the tibia underwent excision of the pseudarthrosis and double onlay bone grafting. Stability was maintained by extending intramedullary rods. Clinical union was achieved in all cases at a mean of 8.6 months (range six to 11). The rods extended by 15.7% (range 2% to 31.4%) as growth occurred. One rod was removed because of infection and a vascularised free fibular graft was subsequently performed. The extending rods provided stability while union occurred and did not require revision as the legs grew. The rods can be removed easily and have not jeopardized further surgical options.
We made a prospective study of 111 children with acute hip pain to assess whether ultrasound can replace traditional radiography. An effusion was diagnosed in 71% by ultrasound but in only 15% by radiography. This effusion persisted for a mean of nine days; symptoms lasted for five days. Two patients found to have Perthes' disease had longer-lasting effusion and symptoms. Patients without an effusion had no obvious cause for their pain, so the pressure of an effusion from a transient synovitis does not account for all patients with irritable hips. Patients with an effusion persisting for over 24 days (the mean + 2 s.d. of our series) had more symptoms, a significantly larger effusion and greater limitation of movement. They may be more at risk for avascular necrosis. We found that radiographic examination influenced the immediate management of only two patients, those with Perthes' disease. We therefore propose a protocol of management for irritable hip, using ultrasonography at the first presentation of certain categories of patients. This would reduce the number of early radiographs by 75%.
We report the results of using 83 expanding intramedullary rods in 24 children with osteogenesis imperfecta after a mean follow-up of five years three months. In all, 62% of the rods have expanded after one primary operation. Thirty-four additional operations were necessary; 11 for the correction of rotation or angulation deformities and 23 for revision of the rod or T-piece. All these revisions were successful. Complications were more frequent in children who required very small rods. Problems with Bailey-Dubow rods led to the development of the Sheffield rod system; 17 bones treated with these rods are included in the series. Before surgery only eight of the 24 children were able to walk but at review 20 children were walking, 15 without walking aids. Elongating intramedullary rods should be available to all children with osteogenesis imperfecta as they improve walking capability, reduce the number of fractures, prevent deformity and allow integration of the child into society.
We report nine cases of irreducible congenital dislocation of the knee which were treated by early operation with good results. All were resistant to conservative measures and operation was performed at an average age of nine months. The essential abnormality was a short quadriceps muscle together with subluxation of the hamstring muscles to lie anterior to the axis of knee flexion. The quadriceps tendon was lengthened by VY-plasty and in six cases additional length was gained by proximal mobilisation of the muscle. After operation all the patients were able to walk.
After having had a standard decompression for anterior compartment syndrome, five patients presented with persistent symptoms and pressure values above normal. A repeat procedure combined with fasciectomy relieved their pain; postoperative pressure values were normal.
We present three cases of a previously undescribed condition characterised by unilateral tibia vara associated with an area of focal fibrocartilaginous dysplasia in the medial aspect of the proximal tibia. The three children affected were aged 9, 15 and 27 months respectively. Two required tibial osteotomy, but in one the deformity resolved without treatment. The pathogenesis of the focal lesion remains conjectural; the most likely explanation is that the mesenchymal anlage of the tibial metaphysis has, for unknown reasons, developed abnormally at the insertion of the pes anserinus.
A cortical bone graft on a muscle pedicle was taken from the ulna and transferred to bridge a complete defect of the radius in 16 dogs. In 14 control dogs a free graft was used, that is, one without a muscle pedicle. Union in the group with pedicle grafts was far superior to that in the group with free grafts, mainly because in those with pedicle grafts there was good subperiosteal new bone formation from active viable periosteum. In six of the pedicle grafts the viability of some osteocytes was retained over a 12-week period and in five the graft was almost completely replaced by new bone.
Seven pectoralis major transfers in children suffering from bilateral paralysis of elbow flexion due to arthrogryposis or to trauma are reported. A technique is described in which the muscle is mobilised from the clavicle to allow the tendon of insertion to be attached to the biceps tendon at the elbow. The biceps tendon was found to be present and could be mobilised forwards in all the arthrogrypotic elbows. Subjectively, the results were considered by patients or parents to be very good in six cases and fair in one. Elbow flexion power against gravity and against some resistance was achieved in all patients except one. The overall function was very good in one elbow, good in two, fair in three and poor in only one. The merits of the various procedures described for the restoration of elbow flexion in arthrogryposis are discussed. It is concluded that total pectoralis major transfer by the method described here has given the best results.
Excellent results can be achieved by plating fractures of the shaft of the humerus in patients with multiple injuries. This helps in nursing care and in the management of other injuries. In 38 patients admitted to a regional trauma centre, 39 humeral shaft fractures were plated. There were 27 men and 11 women, with an average age of 31.5 years. Fourteen of the humeral fractures were compound and 20 had significant comminution; 23 were fixed by a plate on the day of admission and all 39 by the twentieth day. Follow-up of 34 fractures showed that all had united, 33 primarily. All patients but one had a fully functional shoulder and no patient with a fractured humerus alone had lost any elbow movement. Complications were rare--one case each of non-union, fixation failure and infection. No permanent nerve injuries were produced at operation. The plating of fractures of the humerus in these circumstances has been shown to produce excellent results and has a place in the management of the patient with multiple injuries.
We report the ulnar impingement syndrome, which is caused by a shortened ulna impinging on the distal radius and causing a painful, disabling pseudarthrosis. Of the 11 cases reported, 10 were due to excision of the distal ulna after injury to the wrist; the other was a result of a growth arrest after a fracture of the distal ulna in a child. The symptoms are a painful, clicking wrist and a weak grip; clinical examination reveals a narrow wrist with pain on compression of the radius and ulna and on forced supination. Radiographs in the majority of cases show scalloping of the distal radius corresponding to the site of impingement. The mechanism by which ulnar impingement occurs after radio-ulnar convergence is illustrated. The plan of management for the young patient with traumatic dysfunction of the distal radio-ulnar joint is discussed; excision of the lower end of the ulna is not advised in such patients.
Ruptures of the calcaneal tendon which present late may be repaired using carbon fibre to induce a neotendon. The operative technique is described and the results of five cases reviewed. The average muscle power obtained was 88% of normal, and the thickness of the neotendon was 148% of that of the normal side. It would appear that this tendon formation in man is comparable to that previously described in sheep.
There are differences of opinion about the pathogenesis of Perthes' disease. All are agreed that it is due to ischaemia, but the cause of this and the size and number of infarctions are in dispute. Through the generosity of the contributors six whole femoral heads and core biopsies of five other cases have been studied radiographically and histologically. The findings ranged from an ischaemic arrest of ossification in the capital articular cartilage without infarction to multiple complete infarctions of the epiphysial bone. The ensuing reparative process contributes to the pathology, which is of a range to warrant grading or grouping.
1. Twenty-one cases of congenital dislocation of the hip were found on examination of 1,881 consecutive neonates on the first day of life, giving an incidence of eleven per 1,000 live births. 2. Insignificant high-pitched "clicks" were noted in 10 per cent of newborn children. 3. Conversion of half of the patients with hip dislocation to normal occurred during the first post-natal week. 4. Joint laxity was not a feature of the newborn with congenital dislocation of the hip. 5. Oestradiol, oestrone and oestriol were estimated in twenty-fourhour urine samples collected from sixteen patients with congenital dislocation of the hip and nineteen matched controls during the first six days of life. No significant differences in oestrogen output between the two groups were found. 6. The hypothesis that congenital dislocation of the hip is a result of an inborn error of oestrogen metabolism in the newborn is not supported.
1. Six cases of malunited anterior Monteggia fracture have been treated, five of them successfully, by open reduction and reconstruction of the orbicular ligament by turning down a slip from the triceps tendon. 2. One relapse occurred after a slight injury; this was because of an unsuitable triceps tendon. 3. A slip from the triceps tendon has retained reduction of the head of the radius in a patient with congenital dislocation of the radial head.
One of the aims of this work was to find criteria by which the quality of bone as a supporting tissue might be judged. This inevitably involves discussion and, if possible, assessment, of the relative importance of the inorganic and organic material of the bone. It is relatively easy to measure the mineral content, and for that reason it has always received more than its due share of attention. In the present experiment the composition of the ash of all bones was remarkably constant, with a Ca/P ratio of 2. Furthermore, X-ray crystallography showed that the structure of the inorganic material was the same in all cases. The great difficulty of measuring variations in the quality of the organic material which is, of course, protein in nature makes it impossible to say how much it influences bone strength. Since at least 40 per cent. of the bone is collagen, either a quantitative or a qualitative alteration might alter bone strength. X-ray crystallography revealed no qualitative differences in the collagen material of bones of the three groups; so that for the present it would seem safer to assume that alterations in the physical properties of the bones are due to variations in the relative proportions of organic and inorganic constituents (Dawson 1946, Bell These experiments show that the three diets produce highly significant differences in the percentage of ash, in SB, and in E. It is possible that some variations in the percentage of ash are due to variations in the absolute collagen (weight of collagen in unit volume of bone substance); but the range of variation in the percentage of ash leaves no reasonable doubt that differences in percentage ash between the diet groups are due essentially to differences in absolute ash. Presumably the collagen contributes something to the strength of the bone; but the indications are that it plays a minor part and that the relative weakness and flexibility of rachitic bones is due to decrease in the absolute ash content. Within any one diet group, the relation between percentage ash and the other two variables, SB and E, is masked by other sources of variation such as those associated with the many measurements involved; and thus the correlation between percentage ash and SB, and also between percentage ash and E, is not significant. At first sight, the scatter diagrams (Figs. 5 and 6) appear to indicate a correlation between ash and SB, and between ash and E. Closer inspection shows, however, that the apparent trend is due largely to differences between the means of the diet groups, and that the points within any one group show no such obvious trend. Figure 7 shows that the position with regard to correlation between SB and E is very different. Here there is an obvious trend within each diet group; the amount of scatter is very much less. Calculation shows that, even when the differences between the means of diet groups is excluded, there is still a significant correlation between SB and E. The question of the correlation between the three variables is discussed more fully in the addendum to this paper. Although the "goodness" of a bone is usually judged by its breaking stress, the experimental findings recorded above suggest that it may be assessed equally well on the basis of elastic properties as shown by Young's modulus. Normal bones, group S in these experiments, were elastic up to 79 per cent. of their breaking stress (Table II): the poorer bones of groups R and N were, however, only a little inferior in this respect. In some cases there was no apparent deviation of the load-deflexion curve from a straight line until the bone was about to break. Such a curve was published in the first paper of this series (Bell, Cuthbertson and Orr 1941), but in the light of further experience this curve is scarcely typical. The terminal falling over of the curve is illustrated in Figure 4 and is much more marked in the bones of group R. While stress at the upper limit of elasticity varies over a wide range in the three groups (Table II and Fig. 4), the strain at this point is remarkably constant at about 1·5 per cent. This same percentage displacement must occur between the molecules of the bone material at the elastic limitâand it may be that, up to this amount of molecular displacement, the deformation is reversible; but that beyond it, plastic changes occur. We have no evidence as to whether the limiting displacement concerns mineral or protein constituents of the bone, or both. We have already commented on the remarkable strength of bone material (Bell While Young's modulus is of interest, both on its own account and as an index of the quality of the bone, its close association with breaking stress suggests that it might be used to predict the maximum load which a bone can carry safely. Since E, unlike SB, can be measured without damage, useful information might be gained by measuring the elasticity of living human bones.
